This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Monday, 4 May 2009

Why don't nurses smile?

I smile a lot during the beginning of my shift before the hunger, and the sheer terror of the reality of what I am faced with really starts to kick in. Admittedly it is forced. I care very deeply about my patients, and I don't wish to make them think that I don't want to look after them. But the pressure I am under makes me want to run away screaming. I was less scared on that flight to St. Louis where the 02 masks dropped and we had to make an emergency landing and go down the chutes, than I am at work. Thank god this blog is anonymous because in real life I would never, ever admit that I am more scared at work than I was that day in Missouri. I felt more in control in that situation than I ever do at work. Admittedly, I was probably in a bit of shock on that plane, and no, we didn't crash.

Buy the time I reach hour 10 without anything to eat my human side takes over and I can no longer smile. I am always so scared that I will hurt or kill someone because I cannot be ten places at once. Would I simply lose my job and my registration? Or would it go to a criminal court as well? There is no back up and no support. The relatives troop in ready to have a go at me for anything they can find wrong. Grandpa hasn't been shaved, grandma doesn't have her slippers. And I can't even get past them to get to my septic patient with her IV antibiotics, and IV fluids. Her BP is bottoming out and she is becoming vacant and unresponsive. As I try to get past them they imply that I am being rude to them.

After that I need to get back to check on the previously hypoglycemic patient who seemed better last time I checked him. How long ago was that? He has been having these hypo episodes, not due to the usual cause and no one knows what is going on with him yet. After I clear that I can get to the controlled drugs for the cancer patient. IF I get all that accomplished then I can get to all the drugs that were due over an hour ago, and if I can get through that then I can try and conquer some basic care. It has been like this all day with no let up. Never has there been more than 90 seconds where I could carry on uninterrupted. Never. Never. Everything I have to do has to be accomplished in 90 second blocks of time in between interruptions, sometimes less. I've just had 10 hours of that.

I lose the ability to smile at this point. I just want all my patients to be safe. I am so scared that tiredness and hunger are going to cause me to lose my concentration and I am going to fuck something up. Focus focus focus. Push yourself and keep going. Now someone needs a heparin drip immediately. Septic patient first. Can I organise Mr. Smith's heparin drip and all the ins and out of that at the same time that I make up the syringe driver for Mrs. Jane? Can I do both those things while I turn Mrs. Peel? She has grade 3 pressure sores and hasn't been turned in hours.

Damn. I have to prioritise the heparin infusion first. Got to get the right heparin, syringes, tubing and pump, set it up, cannulate the patient which on it's own takes forever, organise blood draws etc. If I keep getting interrupted through that, the patient waits longer and longer to have his infusion.

Then I have to fight my way through hordes of visitors and call bells to get to Mrs. Jane's syringe driver for pain control She has already been waiting for hours. Then after I clear that I can turn Mrs. Peel. By the time I finish sorting out the heparin infusion and get to Mrs. Jane she will have been waiting in pain way too long. Mrs. Peel's pressure sores and the fact that she has been on her back for hours and hours is also weighing on my mind. If I run past the call bells and people shouting for help I can get to the hep infusion up and running, 30 minutes later get to the syringe driver and 20 minutes after that get to Mrs Peel. I usually have 15 patients. So multiply this scenario by 5 all day long. Then factor in the fact that the nurse never goes more than 90 seconds without an interruption, and someone who doesn't understand the situation trying to steer her into another direction.

OMG the hypoglycemia patient!!!! Oh fuck!!!!

Drop the heparin infusion and leg it back down the ward past the call bells, the crying, the begging for help. The hypo patient is again very hypo, pale, sweaty and vacant but I can get sugar gel into his mouth safely,still will need an IV. I need more supplies. Back down the ward I leg it still past all the crying and begging patients and hordes of visitors waiting to pounce. Up and down the ward 3 times, past all these really pissed off people to get every supply I need. The ward lay out is terrible.

I start to think about what would have happened if I had stopped to answer the myriad of requests for the commode and pain killers that were communicated to me in between drawing up that heparin infusion and realising that it had been to long since I checked back on the hypo man. I may have found a body in that bed. And then I would have had to call his family. My blood runs cold, my stomach goes into knots and I feel a bit sick myself.

The septic patient hasn't gone anywhere and I haven't been back to him since I hung those antibiotics and IV fluids. Let's hope he didn't have any kind of allergic reaction. Let's hope he is still alive. He never should have been left in the first place. Still there was the heparin infusion, the pain meds for Mrs Jane. The hypo patient. Back down the wards, past the bays of really pissed off patients ringing their call bells, shouting for help and hordes of visitors ready to pounce.

I don't think that there are a lot of people who can smile and look happy in this scenario. Why are nurses expected to?

Are we supposed to be superhuman? They don't even pay us for all the hours we work for christ's sake.

And yes. Academic degree educated nurses are taught about basic care. Very much so. My first semester of nursing school was anatomy and physiology , nutrition, and pharmacology lectures in the morning and 5 hour lectures of NURSING 101: BASIC FUCKING CARE in the afternoon. Bed making. Bed bathing. Hygiene. Skin care. Pressure area care, etc ,etc, etc,etc,etc,etc,etc. The next day was a 10 hour placement on a ward. Fuck up a bed bath or on bedpan duty and Mrs. Lewis, the nursing 101 instructor would have you for her lunch, in front of everyone. And the next day was lectures again. The day after that was wards again and so on and so forth.

We did this for months. That was first semester only. 10 hour days, baby. It got harder later on. Especially when they threw chemistry and microbiology on top of advanced medical surgical nursing lectures and constant ward placements in second semester. The microbiology, anatomy and physiology and chemistry etc were taken with other university students who also needed to take those courses, not just other nursing students.

We were taught nursing on our nursing courses. Not medicine. Not how to pretend to be a doctors. It was nursing that we were taught. God forbid if we tried to put a medical diagnosis on our care plans and schematics rather than a nursing diagnosis. Our nursing professors would have had their rulers up our backsides, flinging us out of school. This was 1994. All right all right I didn't train in this part of the world but still.

The new graduated nurses that I am working with now here in the UK have a very good handle on basic care. The kids and the carers do silly things sometimes. But the newly qualified nurses that we have had are pretty damn good. The vast majority of new nurses and nursing students were Health Care Assistants for years (decades even) prior to attending nursing school. How could they not know how to bath a patient or make a bed?

*Patient names in this post were invented by me and are not based on real people.

32 comments:

Anonymous
said...

You know, the only way I've ever gotten through to people about nurse patient ratios is by saying OK, if (insert idiots childs name here) was in a daycare with one person for twenty five under five year olds, would you leave (childs name) there? Remember, (childs name) is healthy as would be the other 24 children. So why do you expect to do it with your grandmother who is sick, has an IV in her arm, doesn't know what day is is and needs help going to the bathroom too?

Little Tommy is also less likely to pull out his IV cannula and stab himself in the eye with it. But my grandma with dementia will.

If my sensible 9 year old and my 98 year old grandma were both in hospital at the same time, I would run back and forth but spend more time watching grandma. That is assuming that both were stable. It would be different if my child was dying or something.

My little boy would not eat his own faeces if left alone for 5 minutes and he would not strangle himself in his IV tubing after less than 5 minutes unattended. Grandmother will. And when she was young she was a gorgeous, lady like, intelligent and classy woman. Old age fucks up the best of us.

It kills me when people say that it is the nurses who are uncaring. They need to look in the mirror.

One of our students had a good thought the other day. She said

"I think that when these families kick off and scream at nurses about minor things without taking in what is going on in the ward,and the staffing etc, that it is really all about their own personal guilt".

Bingo.

They cannot deal with the realities of the indignity of old age, their own mortality, their loved ones mortality, the fact that their caregivers have other patients and the reality of sickness and death and just how horrific it is, even in these modern times. And the nurses become their punching bags.

"I know NHS staff are often overworked. But so are a lot of people in customer facing positions, stress is part of the job. My boyfriend, for one, who works in a jobcentre and has to face all sorts of rude and unpleasant people all day, but still stays polite and helpful and professional. I think that in some cases doctors and nurses forget they are working in customer service - just because they customer pays indirectly through taxes does not change this. People seeing doctors and nurses are as a rule unwell, and usually worried and scared about this. A smile and a few kind words, or an apology for an appointment overrunning, cost nothing really and mean a lot to the patient."

saw this posted on another forum and was really tempted to post a link to this blog entry. likening working in a job centre to being a nurse hmmm

What a joke. I have had other jobs outside of healthcare. I now refer to them as vacations with paychecks. Is that too arrogant and bitchy? I don't give fuck.

When do people outside of healthcare work for 14 hours nonstop on their feet without a break or have to worry about hurting or killing someone when they cannot be 10 places at once constantly, all day long. Do they suddenly wake up at 2Am after said shift and think "Oh fuck, did I check this, is the patient okay"

They get paid for all the hours they work and for overtime, they can all go on strike en mass and shut down services without it leading to mass murder.

I worked in retail as a teenager. Lots of customers were rude and abusive. So what. I worked for 8 hours and was able to eat and drink during that time. No one deteriorated or died on me. It was easy peasy. Job centres and stores etc are better staffed with less workload anyway. Fact. My husband sits all day and has lunch out sometimes for a whole hour. He works in an office!!

If you think that abusive customers get abusive and crazy when you don't have the right size trousers available or when their order isn't delivered you should see what they are like when they think that you are responsible for slowly causing their wife an agonising death.

What about the right to have 30 seconds uninterrupted to concentrate on something that would kill a patient if I screw it up?

Unions are worthless to us. We cannot strike and everyone knows it.

What about the right to take a 10 minute dinner once during a double shift without relatives walking by and saying "there's another lazy nurse sat on her arse". Being on the ward is like being in a fishbowl. There is no where to go where you cannot be seen and it is dangerous to leave the ward on your breaktimes. Never can I read notes or bleep a doctor and wait for him to call back without someone implying that I am hanging around the station to avoid patients. People are just so thick.

What about the right to be able to leave in the middle of a shift because my wee boy is puking at school and my husband is away on business? I was the only staff nurse on duty that day and had to wait over 5 hours for the next shift to come in and take report before I could leave. Management could not (or would not) get a nurse to relieve me. If I would have walked out and left the patients to go to my little boy I would have lost my registration for patient abandonment and caused harm to a patient. So for 5 hours he slept on a chair and puked in the headteachers office.

My husband works in the private sector and his annual leave is as good as mine.

What if I am so sick I cannot concentrate? If I worked at the jobcentre I'd drag myself in anyway. But on a 12 hour shift as a nurse where there will be no stopping and I have complex and immunocomprised patients? No fucking way.

Glam...If you really do believe that the 'benefits' you have listed above outweigh the conditions that Nurse Anne describes on this blog, (and I am presuming you have taken the time to read the blog...) ...then intelligent response goes out of the window. I feel I would be very much wasting my time.

What makes you think that we haven't worn ourselves out "challenging" management.

Officially.

Nothing changes.

The whole system needs an overhaul.

My husband works in an office. He is not responsible for people's lives. If he needs to walk out due to a family emergency then he does, no problem. He was away the day my son was poorly but other than that he is always the one who walks out of work due to sick kids etc. I would walk out if I worked at John Lewis or Asda, but not as a nurse.

The only way things are going to change is if the public realises that the nurses in the hospital are not equipped to care for them in the way they expect. The nurses' cries fall on deaf ears.

The situation on many of these wards is one of triage, rather than total holistic care. Nothing will change until the public realises how dangerous things are, how important nurse ratios are and demands action.

In the meantime we are just going to keep losing nurses.

Right now, the only way to survive ward nursing is to quit. This cannot go on. We have to stop the abuse and retain nurses.

All we are doing right now is scapegoating nurses over a problem that they didn't create. We must start retaining ward nurses.

Oh and by the way, I don't think anyone from my generation is getting any kind of pension whatsoever. Just my opinion. None of it is sustainable. I never expect to see what I pay into the pension scheme come back my way. None of us should expect to ever see our pension money ever again, unless it's under the mattress.

Unions and NMC have been contacted and have said that they are unable to do anything.

Ignored ignored ignored.

I could go on. Go to my older posts.

Nothing is every going to change because they could not afford to keep these hospitals open if they staffed them properly. They won't budget for nurses to have the resources and number of hands that they need.

Nurses are the glue that holds the hospital together and the hospitals are run with our blood sweat and tears.

I have already been on wards and been useful filling out blood forms/bottles, checking some paperwork etc.I actually find it fun. If I just go up to a ward and offer my help (rather than asking for tutoring or something!) would it be accepted?

I wonder whether, instead of attacking, Glamorganist considered making constructive suggestions and not being quite so confrontational. That wouldn't have been so successful a troll, however.

Publishing the reality of modern medical/surgical nursing is important. Helping non-nurses to understand the implications of impossible ratios is important. Hell, after a tough shift just venting is important.

Statements like "Double shifts are surely voluntary so you have the right to refuse to do them" ignore the dilemma of modern nursing, which goes something like this:

"Do I leave my colleagues to fend for themselves under unsafe and inhumane conditions in order to preserve some semblance of a private life, or do I sacrifice myself so that all of us have at least a chance of managing safe practice?"

Fortunately, I work in an area of the world where this rarely, if ever, comes up. However I wholeheartedly support any effort to make the struggle of conscientious nurses known to the wider community.

I used to work in A&E in a very busy city centre hospital. (I had 15 years experience of working in A&E.)There used to be 2 hospitals with A&E depts but it was decided that the city really only needed one. They therefore closed one down and now all the patients had to go to one department. Same number of staff on duty though. Who would have thought that waiting times would get longer, that patient care would suffer, that the staff turnover would increase as people could not cope and left and that the general level of violence towards staff (due to long waits etc)would double. I particularly recall one shift where I was the nurse in charge with 5 other staff nurses working with me. We had four critically injurred patients from an RTA each requiring their own individaul nurse and Dr. This meant that there was just me and another staff nurse and a HCA to care for all of the walking wounded who now had an even longer wait because all of the medical staff were tied up in resus with the RTA. The two if us also had 17 other trolley patients to care for, all of who were acutely ill or injured, as well as trying to carry out dressings etc for the walking wounded who actually did get seen. On top of all this we had to try to get patients to x-ray - some of who were unsafe to be left on their own - eg patients with dementia who had fallen and fractured things and had no relative or care home staff with them. Whilst i was running round the department with a broom up my arse sweeping the floors as well i was approached by a woman who was concerned that her son who had been brought in by ambulance had still not been seen by a dr having been there for 3 hours (he was drunk and agressive). I have to admit that she did not think that i was taking her concerns very seriously decided that the best course of action was to shout at me that I was a fucking blonde haired cunt and punched me in the throat causing me to fall back through a curtained trolley bay onto the lap of some poor old man. Her and her son decided not to hang around after that so at least we were one patient down. I remember standing in the middle of this heaving and chaotic department and thinking would anyone notice if i just sat in the middle of the floor and had a nervous breakdown. What happened to the nice lady who assaulted me? She got a conditional discharge for 6 months (let off in other words) and had to pay me £50 compensation at a rate of £2 a week. What happened to me. I now work in the civilised realm of a primary care trust as an advanced nurse pracitioner for the elderly - nice work if you can get it!!

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.